Determining the impact of early and late tracheostomy among severe head injury patients

Abstract

Introduction: Severe head injury patients require a specific treatment plan and nursing care to achieve an optimal outcome. Mild head injury patients may need a few days of hospitalisation for close monitoring and conservative medical administration. However, in severe head injury cases, the patients may require a more extended period of hospitalisation for a series of complex neuro-medical and neurosurgical management. Tracheostomy may be performed on head injury patients with protracted breathing problems. Early tracheostomy, defined as the tracheostomy done less than seven days after initiation of endotracheal intubation, is believed to improve the patient’s functional outcome, health-related quality of life and motivation toward rehabilitation. Objective: This study aims to determine the impact of early and late tracheostomy on the functional outcome, quality of life and rehabilitation motivation among severe head injury patients. Method: This is a retrospective cohort study involving 45 severe head injury patients with tracheostomy done from two hospitals in the Klang Valley. The participant's functional outcome, quality of life and motivation toward rehabilitation were evaluated using GOSE, QoLIBRI and MoT-Q instruments. In addition, the participant's clinical outcomes, including GCS upon discharge, length of stay in ICU and hospital, the incidence of VAP, duration of mechanical ventilation dependency, and decannulation rate, were recorded to identify the associations with the initiation of early and late tracheostomy. Results: There were 45 participants included in this study. Multivariate analyses showed that the association between these variables were significant for the length of stay in the hospital (p=0.035) and duration of mechanical ventilation used (p=0.005). The longitudinal analysis also showed that tracheostomy classification (early and late) had a significant association with the participant's functional outcomes (RR=1.189; 95% CI (1.10-1.28); p=<0.001) and motivation toward rehabilitation (RR=1.470; 95% CI (1.074-2.011); p=0.016). Nevertheless, the analysis did not show a significant association between tracheostomy classification and quality of life (RR=0.470; 95% CI (0.19-1.16); p=0.102). Conclusions: The initiation of early tracheostomy contributes to a favourable clinical outcome regarding mechanical ventilation duration and length of stay in the hospital for patients with severe head injury. Early tracheostomy also was significantly associated with functional outcomes and motivation toward rehabilitation, even though the association with health-related quality of life was found otherwise. Continuous follow-up assessment is proposed to reevaluate the impact of early tracheostomy on all variables. A comprehensive and details protocol for the initiation of early tracheostomy is recommended to be devised to maximize its benefit of it for patients with severe head injury.